This presentation is customizable for your child This presentation is customizable for your child. It is can be used as an educational in-service for teachers and school personnel. It is intended to be given as a presentation, but printing this out for each attendee of an in-service meeting is ideal. You can also ask that a copy of this presentation in kept in your child’s permanent file, in the nurse’s office and in your child’s classroom. One mother even asked that the teacher keep a copy in her folder for any substitute teachers. Delete this slide before use at your school Anywhere you see {insert child’s name – or other text in brackets} highlight the words and brackets and type your child’s name or pertinent information Insert photos of your child throughout. The more personal you can make this presentation, the more impact it has on school personnel Check the notes section for presentation notes and other tips for slides

von Willebrand Disease (vWD) & (Insert Your Child’s Name) At School

Meet {Insert Child’s Name} Age List siblings, names, ages, grade or school names {Insert Child’s Name and LIST DIAGNOSIS} i.e. Has Type IIvWD {LIST HOW MEDICATION IS GIVEN} i.e. Has a port – venous access to infuse factor/orally/nasal spray Developmentally on target {Add photo of your child here} Customize this slide about your child!!! Add photos on the right hand side! May want to mention your child’s factor schedule (i.e. “Little Johnny infuses on Monday, Wednesday, Friday and takes ___ units/kilo of factor VIII or IX via IV push. Parents will infuse Little Johnny before school on those mornings.” )

Definition of Bleeding Disorders A group of hereditary bleeding disorders in which there is a deficiency of one of the factors necessary for coagulation of blood. Does anyone know someone who’s living with a bleeding disorder? Today we are specifically discussing Hemophilia Von Willebrand Disease affects males and females equally. However, because symptoms can be mild, many people affected have not been diagnosed. People with VWD have decreased or malfunctioning Von Willebrand factor (VWF) activity and therefore cannot form a proper platelet plug.

Did you know? von Willebrand Disease is the most common type of bleeding disorder, affecting an estimated 1% of the world's population.

von Willebrand Factor (VWF) VWF is the protein that makes platelets stick together to form a platelet plug VWF is a carrier protein for factor VIII VWF ensures that there is enough factor VIII in the blood stream, and carries it to the site of injury, and protects it from being broken down in the blood stream People with VWD have decreased or malfunctioning Von Willebrand factor (VWF) activity and therefore cannot form a proper platelet plug

Types of von Willebrand Disease Type 1 – von Willebrand levels are lower than normal Type 2 – there is a defect in the structure of the von Willebrand protein that causes lower than normal VW factor protein activity Type 3 – there is very little or no von Willebrand protein produced at all {Insert patient’s name} has von Willebrand Disease Type _______ Tell the audience about your type. Also, there are many types of Type 2 vWD: Type 2a – the level of VW factor is reduced, as is the ability of platelete to clump together Type 2b – although the VW factor is defective, the ability for platelets to clump together is actually increased. Type 2m – the VWF is not able to stick to the platelets and therefore a platelet plug is not properly formed. Type 2n – Also called type 2 Normandy. Type 2n occurs when there isn’t enough VWF to carry the factor VIII protein to the site of injury and therefore there are decreased levels of factor VIII to form a fibrin clot.

People with von Willebrand Disease bleed longer, not faster. People with von Willibrands Disease are missing, or have low levels, of a clotting factor – this makes it difficult for the blood to form a clot.

Degrees of Severity {Insert patient’s name} has ___ vWD Type of vWD Type I Symptoms are usually mild Type II Symptoms are usually moderate Type III Symptoms are usually severe Bleeding can be mild, moderate or severe within each type of vWD. The severity depends in part on the level of VW factor activity. Blood type plays a role in the levels of VW factor found in the blood. Type O blood often has lower levels of VW factor.

Symptoms of von Willebrand Disease Nose bleeds Prolonged bleeding from minor cuts Heavy of longer than usual menstrual bleeding Blood in the urine Blood in the stools Large bruises Hematomas Gums bleed easily Heavy periods and/or periods lasting more than 7 days Share with school personnel which of these symptoms are most common in your child

Explain that you will discuss each of these kinds of bleeds in detail.

Types of Bleeds Joint bleeding Muscle hemorrhage Soft tissue - bruising Life threatening bleeding Others - mouth, nose, scrapes, minor cuts Explain that you will discuss each of these kinds of bleeds in detail.

Joint Bleeding Early signs of joint bleeding include bubbling, tingling and heat at the joint *This is the best time to start treatment Swelling and pain set in As the joint swells, it feels boggy, and range of motion is limited Child may not be able to bear weight or move a limb. Knees, Ankles & Elbows most often affected KEY POINT: Child can feel a joint bleed LONG before anyone sees any outward symptoms In the picture, Point out the swelling, size and compare the right knee (which is bleeding) to left

Muscle Bleeding Signs and symptoms very similar to joint bleeding, but also can include tightness and/or shininess of skin Muscle bleeding is very painful Usually happens in arms and legs Significant blood loss can happen quickly Leg, thigh, calf, forearm and groin most affected areas KEY POINT: Child can feel a muscle bleed LONG before anyone sees any outward symptoms Muscle bleeding is the second most frequent site of bleeding. Any area of the body can be affected but frequently the extremities are involved. Large muscle bleeding can lead to nerve compression (i.e. iliopsoas, thigh - see picture). Significant blood loss can occur in large muscles before appreciable swelling is evident. Bleeding into small muscles can also cause compartment syndrome (i.e. forearm, calf). Signs and symptoms of muscle bleeding may include: Vague ache or pain Heat Swelling Inability/unwillingness to move muscle Tightness of skin Shininess in skin

Soft Tissue Bleeding Soft tissue bleeding is primarily characterized by bruising and hematomas (raised bruises) Many children with vWD have significant bruising all over their bodies Treatment is generally not needed, but ice can help with comfort This slide illustrates common soft tissue bleeds in children. The child in the picture has a soft tissue bleed following a peripheral venipuncture. Applying firm pressure to a venipuncture site for several minutes will help prevent bleeding. Bruises and hematomas are very common. Treatment is generally not required. Ice is often very effective.  

Life-Threatening Bleeding Head/Intracranial Nausea, vomiting, headache, drowsiness, confusion, visual changes, loss of consciousness Neck and Throat Pain, swelling, difficulty breathing/swallowing Abdominal/GI Pain, tenderness, swelling, blood in the stools Iliopsoas Muscle Back pain, thigh tingling/numbness, decreased hip range of motion In the case of a head bleed, call 911. Need to call parents immediately if you notice any signs of these kinds of bleeds Iliopsoas Muscle

Other Bleeding Episodes Mouth bleeding Looks like more than it is, as it is mixed with saliva Child may vomit Feces may be black (from swallowed blood) Nose bleeding Sit up, pinch bridge of nose, cool pack on back of neck If longer than 20 minutes, call parents Scrapes and/or minor cuts Wash, pressure, dressing Call parents if bleeding persists

Treatment of Bleeding Episodes Early and appropriate treatment of each bleeding episode is critical to minimize complications. Treatment may vary depending on the type and severity of the disorder, as well as response to previous therapy and other medications the person may be taking The goal of this slide is to get the school personnel to understand how vitally important early treatment is key to treating bleeding episodes. The recognition of bleeding episodes and treating bleeds as early as possible can help prevent complications such as the lost of range of motion, arthritis and muscle atrophy Source: Butler. Basic Concepts of Hemophilia 2001; 3; 3.

Prophylaxis (or prophy) People on prophylaxis infuse their treatment on a regular schedule to prevent bleeds from occurring. There are two types of prophylaxis: Primary – This type of treatment is usually started in young children to reduce or prevent joint disease and it is continued indefinitely. Secondary – This type of prophylaxis is usually short term and it is started when a bleed has occurred and continued on a regular schedule for a defined period of time. Advantages: Reduced risk of joint damage Ability to participate in sports and other physical activities Reduced risk of spontaneous bleeding {Insert Child’s Name} is on {fill in the blank} prophy schedule Delete this slide if your child does not do prophy on a regular basis Disadvantages of prophy: Frequent injections Cost – Factor replacement is very expensive. An average prophylactic dose is 25 units per kilo. Each unit costs approximately $1. For example, an adult weighing 150 lbs., would inject 1,700 units per dose. This equals a cost of approximately $1,700 per dose.

Treatment Administration In {insert patient’s name}, is administered {insert procedure} Treatment can be kept {insert where at school} and should accompany {insert patient’s name} if transported to the hospital Use this slide to talk about how your child is treated. Use the pictures already placed or use pictures of your child

Bleeding at School Wash the area with an antiseptic soap If a child says he is having a bleed or is limping or not using an arm: Contact parents immediately Have the child elevate the body part that is bleeding Apply ice to the area Remember, the child can feel a bleed before there are any outward signs For superficial cuts or scrapes: Wash the area with an antiseptic soap Apply firm pressure Apply a dressing Contact parents if bleeding persists

Things to Expect vWD is unpredictable! May be covered in excessive bruising Some older bruises may become lumpy or hard May come to school “accessed” Needle inserted into his/her port Will be covered by tape and his/her clothing May come to school wrapped in ACE bandage or Coban, or other device Medication can be kept in nurse’s office Insert pictures on right hand side – maybe of your child in some of these situations – ACE Bandage, with bruises, etc. It’s possible he may missed school due to bleeding episodes. The parents agree to communicate with school to facilitate make up work, etc. He may also come to school using assistive devices. It’s possible he could be in a wheelchair, on crutches, etc.

When to Call Parents If {insert Child’s name} says something hurts Injury to joints ANY head or neck injury Non use of a limb or swelling, warmth or redness in a limb Broken bone Cut requiring sutures Injury to torso (especially chest wall) or kidney area If your child has a port, stress that it’s extremely important to call the parents immediately. A fever is a sign of a possible port infection which can be life threatening. Fevers must be thoroughly checked with blood culture to determine the cause of the fever. Be sure to note: The parents will ask questions to determine how a bleeding episode started or how the injury occurred. Do not mistake this questioning as blaming – it’s only so the parents can help the medical providers determine the best course of treatment.

What Does This Mean in the School Setting? All adults in contact with {insert Child’s name} should be aware that there is a child with vWD under their supervision A care plan should be made with the medical staff, school personnel and parents Parents will make sure this is in place with nurse Key people should be made aware of the plan

Additional School Information {insert child’s name} should not be treated differently than any other child in the classroom Leave it up to the parents and/or the child to share with others that he has vWD There are no learning disabilities that are associated with vWD Child may have pain issues: Could have acute or chronic pain Medication side effects Add anything here that is specific to your child

Activities Unless recovering from a bleeding episode: Should participate in regular gym class Should go on all planned field trips Should play at recess with classmates Some activities restrictions: No contact sports May need immobilization during or after a bleed May need some alternative activities for inclusion in physical education, recess, etc. Can play along with other kids and do the same activities as others Pay careful attention at recess & PE No rough-housing with other kids Does not have to wear helmet as of now No jumping off equipment Use equipment properly (no going up the slide, don’t come head first down slide, no jumping off play-sets, etc.) Customize to your comfort level; items listed are only intended as examples from other parents. Prefer that he not be excluded from activities, but intergraded in other manners. For example, he shouldn’t play dodgeball, but he can be the “watch” and help spot others who are tagged out.

How Much Do Other Adults Need to Know? If other parents ask about {insert child’s name}, they can be told: He/she has a medical condition He/she has von Willebrand Disease He/she has a bleeding disorder Encourage them to talk us if they have more questions. We welcome the opportunity to give them more information. You have to decide what’s right for your family in terms of disclosure to persons other than school personnel (other parents and students). If you or your child are not comfortable disclosing to others, you can delete this slide.

How Much Do Other Children Need to Know? If other kids notice bruising, helmet, Medic-Alert bracelet: {Insert Child’s Name} can tell the other kids : “I have special blood” “My blood doesn’t work right” “I’m missing something in my blood” “I get pokes” “I get infusions”

Responsibilities Student Parent School Learn to communicate Tell someone when they are bleeding Do your schoolwork on time Make the same amount of effort as someone without vWD Parent Communicate child’s condition, activity level & treatment Help obtain makeup work Help the child have a positive attitude about school Work with school staff & nurse to develop a medical plan School Monitor student achievement & inform parents of any change to personality, performance Communicate to parent/child any observable sign of a bleed Stress the importance of completing assignments Promote ability and success, not inability Respect privacy and confidentiality

Summary Please treat him/her like any other student Don’t label Don’t overprotect Don’t exclude Don’t overreact Believe him/her if he/she says something hurts CALL if you have any questions! Add any other concerns you have here

Conclusions Remember that {insert child’s name} is a normal child who happens to have a bleeding disorder If you have questions or have ANY questions, ANY time, call the parents!

Thank You! Contact us: hfaprograms@hemophiliafed.org info@hemophiliafed.org